Intraoperative lymph node evaluation using 18F-FDG and a hand-held gamma probe in endometrial cancer surgery - a pilot study

Purpose: The purpose of this pilot study was to assess feasibility, safety, and accuracy of detection of metastatic nodes intraoperatively with a hand-held gamma (PET) probe after administration of ¹⁸F-FDG in patients with high risk endometrial cancer (EC). Materials and Methods: This is a prospective, cohort study. Twenty-two patients with clinical Stage I or II EC with high-risk histologic subtypes who were candidates for open surgical intervention were screened for the study. After screening, there were seven study patients (mean age: 64; range: 53-77) who were eligible for the study. In the entire cohort, there were 61 nodal stations that were assessed with a gamma counter intraoperatively, in vivo and again after removal of the node. All adverse events were recorded and operating room staff was monitored for radiation exposure. Resected nodes underwent histological assessment as per routine clinical practice. Results: Range of maximal counts per second recorded in vivo and ex vivo were 0-86 and 0-17, respectively. Of all the nodes examined, one node was positive for metastatic disease; however, intraoperatively the lymph node readings were not higher than other lymph node basins assessed in same patient. No adverse events were recorded. The surgeons recorded the maximum average radiation exposure of all healthcare personnel with an average exposure of 0.08 mSV per case (range, 0.06-0.15). Conclusion: Use of hand-held gamma probe for intraoperative staging of patients with high risk EC is feasible, safe, and radiation exposure levels for all members of the healthcare team were within radiation safety guidelines. However, its use for detection of lymph node metastases needs further evaluation.

Lymph nodes; 18F-FDG; Endometrial cancer; Gamma probe.

[1] Wartko P., Sherman M.E., Yang H.P., Felix A.S., Brinton L.A., Trabert B.: “Recent changes in endometrial cancer trends among menopausal-age U.S. women”. Cancer Epidemiol., 2013, 37, 374.

[2] Fader A.N., Boruta D., Olawaiye A.B., Gehrig P.A.: “Uterine papillary serous carcinoma: epidemiology, pathogenesis and management”. Curr. Opin. Obstet. Gynecol., 2010, 22, 21.

[3] Giuliano A.E., Hunt K.K., Ballman K.V., Beitsch P.D., Whitworth P.W., Blumencranz P.W., et al.: “Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial”. JAMA, 2011, 305, 569.

[4] Hauspy J., Beiner M., Harley I., Ehrlich L., Rasty G., Covens A.: “Sentinel lymph node in vulvar cancer”. Cancer, 2007, 110, 1015.

[5] Ross M.I.: “Sentinel node biopsy for melanoma: an update after two decades of experience”. Semin. Cutan. Med. Surg., 2010, 29, 238.

[6] Hauspy J., Beiner M., Harley I., Ehrlich L., Rasty G., Covens A.: “Sentinel lymph nodes in early stage cervical cancer”. Gynecol. Oncol., 2007, 105, 285.

[7] Abu Rustum N.R., Khoury-Collado F., Pandit-Taskar N., Soslow R.A., Dao F., Sonoda Y., et al.: “Sentinel lymph node mapping for grade 1 endometrial cancer: is it the answer to the surgical staging dilemma?” Gynecol. Oncol., 2009, 113, 163.

[8] Burke T.W., Levenback C., Tornos C., Morris M., Wharton J.T., Gershenson D.M.: “Intraabdominal lymphatic mapping to direct selective pelvic and paraaortic lymphadenectomy in women with high-risk endometrial cancer: results of a pilot study”. Gynecol. Oncol., 1996, 62, 169.

[9] Delaloye J.F., Pampallona S., Chardonnens E., Fiche M., Lehr H.A., De Grandi P., et al.: “Intraoperative lymphatic mapping and sentinel node biopsy using hysteroscopy in patients with endometrial cancer”. Gynecol. Oncol., 2007, 106, 89.

[10] Frumovitz M., Bodurka D.C., Broaddus R.R., Coleman R.L., Sood A.K., Gershenson D.M., et al.: “Lymphatic mapping and sentinel node biopsy in women with high-risk endometrial cancer”. Gynecol. Oncol., 2007, 104, 100.

[11] Kakhki V.R., Shahriari S., Treglia G., Hasanzadeh M., Zakavi S.R., Yousefi Z., et al.: “Diagnostic performance of fluorine 18 fluorodeoxyglucose positron emission tomography imaging for detection of primary lesion and staging of endometrial cancer patients: systematic review and meta-analysis of the literature”. Int. J. Gynecol. Cancer, 2013, 23, 1536.

[12] Kitajima K., Murakami K., Yamasaki E., Fukasawa I., Inaba N., Kaji Y., Sugimura K.: “Accuracy of FDG PET/CT in detecting pelvic and paraortic lymph node metastasis in patients with endometrial cancer”. AJR, 2008, 190, 1652.

[13] Cohn D.E., Hall N.C., Povoski S.P., Seamon L.G., Farrar W.B., Martin E.W. Jr.: “Novel perioperative imaging with 18F-FDG PET/CT and intraoperative 18F-FDG detection using a handheld gamma probe in recurrent ovarian cancer”. Gynecol. Oncol., 2008, 110, 152.

[14] de Jong J.S., van Ginkel R.J., Slart R.H., Lemstra C.L., Paans A.M., Mulder N.H., et al.: “FDG-PET probe-guided surgery for recurrent retroperitoneal testicular tumor recurrences”. Eur. J. Surg. Oncol., 2010, 36, 1092.

[15] Gulec S.A., Hoenie E., Hostetter R., Schwartzentruber D.: “PET probe-guided surgery: applications and clinical protocol”. World J. Surg. Oncol., 2007, 5, 65.

[16] Chan J.K., Urban R., Cheung M.K., Shin J.Y., Husain A., Teng N.N., et al.: “Lymphadenectomy in endometrioid uterine cancer staging: how many lymph nodes are enough? A study of 11,443 patients”. Cancer, 2007, 109, 2454.

[17] Khoury-Collado F., Abu-Rustum N.R.: “Lymphatic mapping in endometrial cancer: a literature review of current techniques and results”. Int. J. Gynecol. Cancer, 2008, 18, 1163.

[18] Robova H., Rob L., Halaska M.J., Pluta M., Skapa P.: “Current status of sentinel lymph node mapping in the management of endometrial cancer”. Expert Rev. Anticancer Ther., 2013, 13, 55.

[19] Toriihara A., Yoshida K., Umehara I., Shibuya H.: “Normal variants of bowel FDG uptake in dual-time-point PET/CT imaging”. Ann. Nucl. Med., 2011, 25, 173.